Circumcision - A Guide for Parents

In Australia today circumcision of baby boys is rare, and the uncut penis is the normal thing among young people, but many parents are still anxious about the subject.

By
Dr George Williams,
Shane Peterson

In Australia today circumcision of baby boys is rare, and the uncut penis is the normal thing among young people, but many parents are still anxious about the subject. Because Australia has a past history of widespread circumcision, they may be unfamiliar with the normal penis and worried that they will not know how to look after it. They may also have been alarmed by reports in the media about the risks to health supposedly caused by the foreskin, or they may have heard stories from relatives or friends that the normal penis is somehow difficult to look after or prone to problems.

This page aims to answer questions commonly asked by parents who are considering whether to circumcise their baby boy and to reassure them that all these fears are groundless. Boys are exactly right the way nature made them.

Circumcision: Frequently asked questions

Introduction
Parents want to make the best decision for the health of their children, but not all Australian state health departments and medical bodies are equally forthcoming with information for parents on the risks of circumcision and care of the normal (intact) penis.

What is male circumcision?
The word circumcision means “to cut around”. In male infants, circumcision is a surgical operation which involves tearing the foreskin* away from the glans (head) of the penis, clamping it and cutting it off. There are several techniques in use, including one (Plastibel) that is intended to slowly strangle the foreskin, but they all involve cutting, blood and removal of sensitive tissue. The skin of the penis is a complex movable sheath with no clear indication of where it should be cut during a circumcision. This means that the amount of foreskin removed from one operation to the next can be very different, and no two circumcisions are the same.

Does any medical organisation recommend circumcision of boys?
No medical organisation anywhere in the world recommends routine circumcision of boys. Many organisations state that there is no medical indication for routine circumcision, including the Royal Australasian College of Physicians, the British Medical Association, and the American Academy of Paediatrics.

Is circumcision less painful for a baby than for an adult?
Infants experience excruciating pain during circumcision and for weeks afterwards, and they can show behavioural changes such as frequent crying, avoidance of physical contact, reluctance to breast-feed, and sleep disturbance. Local anaesthetic creams such as EMLA are not adequate, and a general anaesthetic poses a significant risk for infants under the age of six months. Circumcision in adulthood is less risky and painful, since men can undergo general anaesthesia and receive pain relief during the post-operative period.

Isn’t circumcision just a “tiny snip” with no risks?
The risks of circumcision include bleeding, infection, damage to the glans and frenulum**, excessive skin removal, scarring, loss of penis, and even death. Infant circumcision carries more risks than adult circumcision, as a baby’s penis is very small and difficult to operate on, and more penile skin is removed than in adults. Excessive tissue removal is a common problem, and this can cause painful erections and even restrict the growth of the penis at puberty.

Will a boy feel upset if he looks different to Dad?
All penises are different, just like noses. Boys don’t have plastic surgery so that their noses look like their fathers’, so why would a baby need his penis to look the same? Different doctors perform circumcision differently, and some remove a lot of skin while others remove only a little. This means the chance of a circumcised boy looking exactly like his father is very slight. A boy is far more likely to be upset if he is circumcised and his father is not.

Is circumcision necessary to prevent UTIs in infants?
Some research suggests that circumcised infants may have a lower incidence of urinary tract infections (UTIs). Approximately 0.188 per cent of circumcised infants and 0.702 per cent of intact infants develop a UTI. This difference is too slight to matter, and female infants have a far higher incidence of UTIs than circumcised or intact boys (5 per cent). Mothers will be happy to know that immediate breastfeeding protects male and female infants from such infections. If a UTI does occur, the most conservative treatment is with antibiotics and more rigorous follow-up in rare cases of recurrent infections. Chronic UTIs are often the result of abnormalities in the urethra or bladder which will usually require internal surgery.

Should a boy’s foreskin be retracted everyday for cleaning with soap and water?
The foreskin* of most newborn boys is stuck to the glans and cannot be retracted. Forcible retraction can result in tearing, scarring and infection, with the result that circumcision may become medically necessary because of the consequent damage. A boy will retract his foreskin when he is ready to do so, and it is normal for this to happen any time between the ages of 3 and mid-teens. After the foreskin has become retractable boys either know instinctively or can be shown how to gently retract and wash underneath it with water. Diluted soap can help with cleaning, but it must be thoroughly rinsed away so as to avoid irritation of the foreskin’s sensitive inner surface. Too much soap can cause skin problems, such as eczema, that used to be blamed on the foreskin.

Are most men in the world circumcised?
Only about 20 per cent of men worldwide are circumcised. Most men (80 per cent) are not circumcised, including the vast majority in Britain, Europe, non-Moslem Asia, and South America. Circumcised men are a minority confined to the Middle East, some African tribes, Islamic regions of Asia, and the USA. The number of circumcised men in Australia and Canada is in steady decline.

Do women prefer circumcised partners?
There is no firm evidence that women have any preference on this question. Women in countries where circumcision is common sometimes state a preference for circumcised partners because this is what they are accustomed to; in countries where circumcision is unknown or rare, women are more likely to state a preference for uncircumcised men. This effect of cultural conditioning should not legitimise the practice. Many women also report smoother intercourse and greater sexual satisfaction with intact partners compared to circumcised partners (1). Most women are far more interested in whether their partner is loving and kind.

Does circumcision affect a man’s sexual function and pleasure?
Circumcision removes complex tissue containing thousands of highly specialised fine touch receptors and nerve fibres. The loss of sexual sensitivity and function is proportional to the amount of foreskin removed; a tight circumcision that prevents movement of the foreskin during intercourse and other sexual activity is particularly damaging. Men circumcised as infants may be unaware of this, but many men circumcised as adults report a definite loss of feeling and functionality.

Is circumcision necessary to prevent penile or cervical cancer?
The principal risk factors for penile and cervical cancer are cigarette smoking and exposure to various strains of the human papilloma or wart virus (HPV), through unprotected sex with multiple partners. Cancer of the penis is an extremely rare disease with less than 1 case per 100,000 men and a median age of diagnosis of 64 years. Circumcised men do develop penile cancer, which can develop on the circumcision scar. Among men, cancer of the breast and of the testicles is more common than cancer of the penis, yet nobody recommends precautionary amputation of those body parts. Cervical cancer in women can now be prevented by a vaccine.

Is circumcision necessary to prevent HIV-AIDS and other STDs?
Although many studies have claimed that circumcision can reduce an adult male’s risk of acquiring sexually transmitted diseases (STDs), there is no convincing proof that the incidence of STD infection differs significantly between cut and uncut men. Studies that claim otherwise are usually done in poor and under-developed countries and do not take into account personal hygiene, complex social customs, education level, medical services, traditional sexual practices, and genetic factors in susceptibility to disease. Similar studies in industrialised nations, such as Australia, find that circumcision does not reduce the risk of STD transmission. There is, however, evidence that circumcision increases the risk of some STDs.

Studies in Africa suggest that circumcision does reduce the risk of infection with AIDS as a result of unprotected heterosexual intercourse. These studies are not relevant to Australia, where AIDS is not a heterosexual epidemic (as in Africa) but a relatively rare disease confined to specific sub-cultures (homosexual men and intravenous drug users). The Australian Federation of AIDS Organisations has stated that circumcision has no role to play in the control of AIDS in Australia.

Apart from all this, reducing the risk of STDs could never be a justification for circumcising infants or children, since they are not sexually active and thus not at risk. Sexual promiscuity and failure to practise safe sex are far more serious risk factors for STDs than normal anatomy.

What about phimosis and paraphimosis?
Phimosis means a foreskin that cannot be fully drawn back to uncover the glans. Nearly all infants and young boys have phimosis, which is the normal condition of the infant and juvenile penis. The foreskin usually becomes retractable over time, and action is needed only if the boy is experiencing discomfort or pain. If phimosis persists it can usually be cured by application of steroid cream (2); radical surgery should only be resorted to if conservative treatment fails.

Paraphimosis refers to a condition where the foreskin has been retracted but has become stuck behind the glans and cannot be pulled forward again. The problem can usually be fixed with cold water and gentle compression, but in rare cases, where the foreskin is very tight, urgent medical attention is required.

Does circumcision make the penis grow bigger?
No. There is no evidence that circumcision makes the penis grow bigger. Logically, if you cut the end off something it must get smaller. One Australian survey actually found that circumcised men had shorter erect penises than men with uncircumcised penises (3).

How did circumcision start in Australia?
During the prudish Victorian era, doctors in Britain (and its colonies) and the USA adopted circumcision and other genital mutilations to control sexual behaviour in boys and girls, and to prevent STDs in adult men and women. Circumcision, clitoridectomy and hysterectomy were prescribed in the false belief that they could prevent or cure masturbation, tuberculosis, mental illness, and an amazing array of other unlikely diseases. Not all British doctors supported these treatments, and female circumcision was banned in 1867, when a woman’s right to make decisions about her own body was recognised. In contrast, male circumcision was continued into the 20th century by misguided physicians who claimed it was necessary in all cases of infantile phimosis and to prevent masturbation, cancer and syphilis.

Why are most Australian boys not circumcised?
Male circumcision lost favour in Britain in the 1940s, when the lack of necessity and the dangers of the operation were recognised These included bleeding, damage to the glans, excessive skin removal and 16 deaths a year in Britain alone (4). Australian paediatricians have discouraged the practice since the 1960s, with the result that the incidence of circumcision has fallen from over 70 per cent of boys during the 1960s to 49 per cent in 1973 and 39 per cent in 1980. At present about 12 per cent of Australian boys are circumcised, but there is wide variation among the states.

Why are more boys circumcised in Queensland and NSW?
The incidence of circumcision tends to be higher where doctors are older and less likely to be up to date with modern medical thinking, or where they come under the influence of powerful circumcision advocates. Tasmania, Western Australia and Victoria have the lowest incidence of circumcision, at around 5 per cent, Queensland has the highest at 20 per cent, and New South Wales the second highest at 15 per cent. Infants born in rural areas are also more likely to be circumcised than those born in a capital city (5). There is no evidence that children in areas where circumcision is more common are healthier than those in areas where circumcision is rare. On the contrary, the Australian Institute of Health and Welfare has found that Australian children have become significantly more healthy as the incidence of circumcision has declined.

Who has the right to decide?
During the decision making process, the most important point for parents to remember is that, just as it is a woman’s right to choose in matters concerning her own body, so it is a man’s right to choose in matters concerning his body. Circumcision Information Australia has received many complaints from adult men who are unhappy about having been circumcised as infants or children. Circumcision is cosmetic surgery, and the appearance of the penis is a matter of personal preference. Only the owner of the penis has the right to decide if he would like its appearance, structure and function altered by circumcision or any other unnecessary procedure.

How can parents get more help with their decision?
Expectant parents should read both the this leaflet and the full Policy Statement on Circumcision issued by the Royal Australasian College of Physicians. These documents are available on the internet or can be obtained in print form by contacting the RACP. For a more comprehensive discussion on circumcision, see the short book Doctors Re-examine Circumcision, at your local or state library.

After reading this material, parents should not hesitate to take these documents along to their paediatrician or family physician for discussion. Alternatively, you can email Circumcision Information Australia.

Glossary:

* Foreskin or prepuce: the movable sheath of tissue on the penis which covers and protects the glans while the penis is not erect (flaccid).

** Frenulum: a very sensitive band of tissue connecting the inner foreskin to the glans on the underside of the penis, sometimes referred to as the male G-spot, since it is very heavily laced with nerves and blood vessels.